Beneficial effects of levosimendan on survival in patients undergoing extracorporeal membrane oxygenation after cardiovascular surgery

Distelmaier, Klaus; Roth, Christian; Schrutka, Lore; Binder, Christina; Steinlechner, Barbara; Gisslinger, Heinz; Lang, Irene M.; Maurer, Gerald; Koinig, Herbert; Niessner, Alexander; Hülsmann, Martin; Speidl, Walter S.; Goliasch, Georg

doi:10.1093/bja/aew151

Cited by 63 publications

(86 citation statements)

References 44 publications

(24 reference statements)

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“…A retrospective, observational, single-center study having assessed 240 VA ECMO patients after cardiovascular surgery reported similar results (34). The authors showed an association between levosimendan treatment and not only successful ECMO weaning [adjusted hazard ratio (HR) 0.41; 95% CI, 0.22-0.80; P=0.008], but also longterm mortality (adjusted HR 0.64; 95% CI, 0.42-0.98; P=0.04) (35). These strategies were reported for very small populations or in retrospective studies and must be confirmed in larger series.…”

Section: Aids To Optimize Weaningmentioning

confidence: 76%

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Weaning from veno-arterial extra-corporeal membrane oxygenation: which strategy to use?

Ortuno¹,

Delmas²,

Diehl³

et al. 2019

Ann. Cardiothorac. Surg

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Refractory cardiogenic shock patients may be rescued by veno-arterial extracorporeal membrane oxygenation (VA ECMO). After a few days of mechanical assistance, the device can sometimes be successfully removed if the patient has partially or fully recovered from the condition that required the use of ECMO. The percentage of patients with refractory cardiogenic shock who are successfully weaned from ECMO varies from 31% to 76%. Weaning does not mean survival, because 20% to 65% of patients weaned from VA ECMO support do not survive to hospital discharge. The high death rate after successful weaning shows that many questions remain unresolved in this field. In this review, we will discuss the various factors influencing survival and a successful weaning from VA ECMO, in addition to weaning approaches proposed in the literature. Based on this information, we will propose a strategy to optimize the weaning process.

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Section: Aids To Optimize Weaningmentioning

confidence: 76%

“…The ability of some medications to facilitate weaning from VA ECMO has been assessed by some (34,35). Levosimendan was assessed in 6 VA ECMO patients with the hypothesis that its remaining effects could favour the weaning from ECMO.…”

Section: Aids To Optimize Weaningmentioning

confidence: 99%

Weaning from veno-arterial extra-corporeal membrane oxygenation: which strategy to use?

Ortuno¹,

Delmas²,

Diehl³

et al. 2019

Ann. Cardiothorac. Surg

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“…Whether the dismal clinical course can be altered by specific interventions remains to be demonstrated. Potential strategies to alleviate the impact of reduced RV function on outcome might include (1) avoiding open heart surgery—eg, showing a preference for minimally invasive/transcatheter approaches; (2) optimizing inotropic treatment; (3) use of pulmonary vasodilators; (4) early use of biventricular assist devices; and (5) prompt evaluation of candidates for high‐urgency heart transplant.…”

Section: Discussionmentioning

confidence: 99%

Impact of Right Ventricular Performance in Patients Undergoing Extracorporeal Membrane Oxygenation Following Cardiac Surgery

Bartko

Wiedemann

Schrutka

et al. 2017

JAHA

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BackgroundExtracorporeal membrane oxygenation following cardiac surgery safeguards end‐organ oxygenation but unfavorably alters cardiac hemodynamics. Along with the detrimental effects of cardiac surgery to the right heart, this might impact outcome, particularly in patients with preexisting right ventricular (RV) dysfunction. We sought to determine the prognostic impact of RV function and to improve established risk‐prediction models in this vulnerable patient cohort.Methods and ResultsOf 240 patients undergoing extracorporeal membrane oxygenation support following cardiac surgery, 111 had echocardiographic examinations at our institution before implantation of extracorporeal membrane oxygenation and were thus included. Median age was 67 years (interquartile range 60‐74), and 74 patients were male. During a median follow‐up of 27 months (interquartile range 16‐63), 75 patients died. Fifty‐one patients died within 30 days, 75 during long‐term follow‐up (median follow‐up 27 months, minimum 5 months, maximum 125 months). Metrics of RV function were the strongest predictors of outcome, even stronger than left ventricular function (P<0.001 for receiver operating characteristics comparisons). Specifically, RV free‐wall strain was a powerful predictor univariately and after adjustment for clinical variables, Simplified Acute Physiology Score‐3, tricuspid regurgitation, surgery type and duration with adjusted hazard ratios of 0.41 (95%CI 0.24‐0.68; P=0.001) for 30‐day mortality and 0.48 (95%CI 0.33‐0.71; P<0.001) for long‐term mortality for a 1‐SD (SD=−6%) change in RV free‐wall strain. Combined assessment of the additive EuroSCORE and RV free‐wall strain improved risk classification by a net reclassification improvement of 57% for 30‐day mortality (P=0.01) and 56% for long‐term mortality (P=0.02) compared with the additive EuroSCORE alone.ConclusionsRV function is strongly linked to mortality, even after adjustment for baseline variables and clinical risk scores. RV performance improves established risk prediction models for short‐ and long‐term mortality.

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“…Here, the VA-ECMO support is kept at 25% for about one hour and if the TEE confirms good functioning, ECMO is stopped and de-cannulation can be performed. Finally, in some studies, evidence was found that levosimendan could increase the chances of the success of weaning trials and the integration of levosimendan in weaning strategies was discussed [54,55]. The maximum hemodynamic response of levosimendan as a calcium sensitizer with inotropic and vasodilatory effects is seen 24-48 h after stopping infusion, but its effects can persist for 7-9 days due to active metabolites.…”

Section: Weaning Strategies From Va-ecmomentioning

confidence: 99%

“…Distelmaier et al could also show beneficial effects of levosimendan on survival in patients undergoing VA-ECMO therapy after cardiovascular surgery. Here, patients in the treatment group received levosimendan within the first 24 h after initiation of VA-ECMO therapy [55]. However, these studies are based on small patient cohorts and prospective randomized trials are needed to further investigate the role of levosimendan in ECMO therapy.…”

Section: Weaning Strategies From Va-ecmomentioning

confidence: 99%

Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation

Lüsebrink

Stremmel

Stark

et al. 2020

JCM

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Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary cardiac and respiratory support and has emerged as an established salvage intervention for patients with hemodynamic compromise or shock. It is thereby used as a bridge to recovery, bridge to permanent ventricular assist devices, bridge to transplantation, or bridge to decision. However, weaning from VA-ECMO differs between centers, and information about standardized weaning protocols are rare. Given the high mortality of patients undergoing VA-ECMO treatment, it is all the more important to answer the many questions still remaining unresolved in this field Standardized algorithms are recommended to optimize the weaning process and determine whether the VA-ECMO can be safely removed. Successful weaning as a multifactorial process requires sufficient recovery of myocardial and end-organ function. The patient should be considered hemodynamically stable, although left ventricular function often remains impaired during and after weaning. Echocardiographic and invasive hemodynamic monitoring seem to be indispensable when evaluating biventricular recovery and in determining whether the VA-ECMO can be weaned successfully or not, whereas cardiac biomarkers may not be useful in stratifying those who will recover. This review summarizes the strategies of weaning of VA-ECMO and discusses predictors of successful and poor weaning outcome.

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Beneficial effects of levosimendan on survival in patients undergoing extracorporeal membrane oxygenation after cardiovascular surgery

Abstract: These data suggest an association between levosimendan treatment and improved short- and long-term survival in patients undergoing ECMO support after cardiovascular surgery.

Cited by 63 publications

References 44 publications

Weaning from veno-arterial extra-corporeal membrane oxygenation: which strategy to use?

Weaning from veno-arterial extra-corporeal membrane oxygenation: which strategy to use?

Impact of Right Ventricular Performance in Patients Undergoing Extracorporeal Membrane Oxygenation Following Cardiac Surgery

Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation

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